Practices In Sonography
Extremity Venous Evaluation (Chronic Disease)
L. Katz, Ph.D., R.V.T.
of North Carolina at Chapel Hill
Hill, North Carolina
Images provided by Cindy Owen, RDMS
Table of Contents
Equipment & Supplies
Patient Preparation & Positioning
General Technical Points
the worksheet for Venous Duplex Imaging: Lower Extremity (chronic venous disease)
Duplex Imaging: Lower Extremity (chronic venous disease)
identify the presence and duration of venous blood flow reversal (reflux) of
the lower extremity
chronic venous disease
[pain, swelling, pigmentation changes, ulceration of the lower extremity]
and pelvic veins: depth of the vessels and the presence of bowel gas
veins: extensive swelling
imaging system: LOGIQ 700, LOGIQ 500
546L, 739L, LA39
setups for venous ultrasound evaluation
for documentation of the study [video, prints, film]
venous ultrasound examination is explained to the patient and any questions
history is obtained from the patient focusing on a previous history of deep
and superficial venous thrombosis, and symptoms of chronic venous disease.
- The examination is
performed with the patient standing, holding onto a frame for support, and
with full body weight placed on the contralateral leg.? The leg being examined
should be slightly flexed at the knee.
examination should follow a complete evaluation of the lower extremity for
the time of day the examination is performed.
- Use a transverse view
to locate the appropriate veins and then perform the venous Doppler examination
from a longitudinal plane.?
care must be taken when evaluating a leg with an ulcer because it may be very
painful for the patient.
- At the end of the
examination, the ultrasound gel should be removed from the patient and any
excess gel should be removed from the transducer.? The transducer should be
cleaned using a disinfectant.
transverse view is used to locate the veins at the appropriate level.
the vein is located, the examination for venous reflux is performed in the
longitudinal plane since the absence or presence of venous reflux is measured
using the venous spectral Doppler waveform (or color Doppler).
Doppler sample volume is adjusted to the size of the vein's width.
angle adjustment/correction is necessary since only blood flow direction and
timing of venous reflux are measured.
Valsalva maneuver is not used because of variable duration depending upon
- Manual compression/release
of the limb proximal and distal to the ultrasound transducer may vary depending
on the examiner and the patient's limb size.? An automatic rapid cuff inflation/deflation
device is suggested for standardized quantitative protocols.? The cuff should
be placed on the limb distal to the ultrasound transducer for the most reliable
width and pressures:
inflation time is for approximately 3 seconds with a deflation time of 0.3
distance from ultrasound transducer should be less than 5 cm.
- A linear array transducer should
be used to evaluate for venous reflux in the deep veins of the lower extremity.
The transducer should be a low frequency linear array (739L 5MHz transducer).
The veins should be located in a transverse view and Doppler evaluation
should be performed from a longitudinal plane.
The deep veins evaluated for venous reflux should include the common
femoral, proximal superficial femoral, deep femoral (profunda), popliteal,
and posterior tibial veins.
A linear array transducer should be used to evaluate for venous reflux
in the deep veins of the lower extremity.
The transducer used may be a higher frequency linear array than the
one used for evaluating the deep veins (LA39 9-13 MHz transducer).
The superficial veins evaluated for venous reflux should include the
greater saphenous vein (near confluence with femoral vein, mid saphenous vein,
and distally on the leg), and the lesser saphenous vein by its confluence
with the popliteal vein.
The superficial and deep venous systems of the lower extremity are
separated by the deep fascia (a echogenic horizontal line) and joined by perforating
veins with valves that direct unidirectional blood flow from the superficial
to the deep venous system.? There are approximately 90 to 150 perforators
per lower extremity and most are found below the knee.? The direct perforators
communicate between the superficial and deep veins and the indirect perforators
interrupt their course in muscular veins before terminating
in the deep veins.
A multi-frequency transducer is used to track the pathway of the perforating
vein from the superficial to the deep venous system.
Although there are many perforators in lower extremity, most patients
have 3 to 5 clinically significant incompetent perforators.? The distal medial
calf is the location for clinically important perforating veins in many patients.?
The calf should be evaluated in a standardized sequence starting just below
the knee and scanning to the ankle.? This scanning technique is repeated,
one width of the transducer's footprint at a time until completing the entire
circumference of the limb searching for perforating veins.
Incompetence of the perforating vein is determined by using spectral
Doppler waveform or color Doppler imaging.
Compression of the limb to augment venous blood flow is performed above
and below the level of the perforator.? Direction of blood flow and the duration
of reflux are documented.
The position of the incompetent perforating vein should be marked on
the skin using a permanent skin marker (if requested by referring physician).?
The mark on the skin should be the exact location where the vein perforates
the deep fascia. The diameter of the perforating vein should be measured at
Some common perforating veins are:
Cockett perforators: Mid to distal calf is the location for the Cockett
perforators connecting the posterior arch vein (Leonardo's vein: off the greater
saphenous vein) to the posterior tibial veins.? The Cockett I perforator is
most distal and is located near the medial malleolus.? The Cockett II perforators
are usually 7-9 cm above the lower border of the medial malleolus and the
Cockett III perforators are located 10-12 cm above the medial malleolus.?
In the proximal calf there are the paratibial perforating veins that
connect the greater saphenous vein to the posterior tibial veins or the popliteal
Boyd's perforator: Just distal to the knee (proximal calf) is the Boyd's
perforator, which connects the greater saphenous vein to the posterior tibial
and muscular veins.
In the calf, perforators may be identified connecting branches of the
greater and/or lesser saphenous veins directly to the anterior tibial veins.
The Bassi's perforator connects the lesser saphenous vein to the peroneal
veins and indirect perforators off the lesser saphenous vein may connect with
the gastrocnemius or soleal veins.
Dodd's perforators and Hunterian perforators are two named direct perforators
located in the thigh.? The thigh segment of the greater saphenous vein is
connected to the proximal popliteal or superficial femoral vein.?
Direction of blood flow is documented by the Doppler spectral waveform
or by color Doppler.
Reflux (retrograde venous blood flow) time is measured on the spectral
Doppler waveform.? Reflux time less than 0.5 seconds is considered within
normal limits and greater than 0.5 seconds is abnormal (some investigators
use greater than 1 second).
The diameter of the perforating veins should also be measured and included
in the report.
The report should specify which veins
were examined and which were omitted because of technical difficulties.
Duplex Imaging: Lower Extremity
Chronic Venous Disease
(Click on images to
Doppler Signal /Color Doppler
Valve leaflets coapt
Perforators: less than 3mm
in calf and 4mm in thigh
Reflux < 0.5 second
Lack of valve leaflet motion
or failure of valve leaflets to coapt
Perforators: greater than
3mm in calf and 4mm in thigh
Reflux > 0.5 second
(Blood flow from deep to the
Venous Duplex Imaging
Katz ML. Peripheral Venous Evaluation. In: Textbook of Diagnostic Ultrasonography.
Hagen-Ansert SL (Ed). Chapter 22, pp. 531-547, Mosby, St. Louis, 2001.
Ridgway, DP. Introduction to Vascular Scanning. A guide for the complete
beginner. Davies Publishing, 1998.
Sandri JL, Barros FS, Pontes S, Jacques C, Salles-Cunha SX. Diameter-reflux
relationship in perforating veins of patients with varicose veins. J Vasc
Surg 30:867-875, 1999.
van Bemmelen PS, Bedford G, Beach K, Strandness DE. Quantitative segmental
evaluation of venous valvular reflux with duplex ultrasound scanning. J
Vasc Surg 10: 425-431, 1989.
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